Should further imaging be done in a patient with a drop in hemoglobin (Hb) after starting Eliquis (apixaban) without a clear source of bleeding?

Should Further Imaging Be Done?

Yes, further imaging and investigation should be pursued immediately in this patient with a hemoglobin drop from 7 to 6.3 g/dL after starting apixaban, even without overt signs of bleeding. This represents a clinically significant hemoglobin decrease that warrants urgent evaluation to identify an occult bleeding source. 1, 2

Why This Constitutes a Major Bleeding Event

This patient meets criteria for a major bleeding event based on the American College of Cardiology guidelines, which define major bleeding as a hemoglobin drop ≥2 g/dL or requiring ≥2 units of packed red blood cells. 1 While this patient's drop is 0.7 g/dL (not quite meeting the ≥2 g/dL threshold), several critical factors make this concerning:

• The baseline hemoglobin of 7 g/dL is already severely anemic, making any further drop potentially life-threatening 1
• Patients with cardiovascular disease have significantly increased mortality risk from hemoglobin drops while on anticoagulation 1
• The absence of overt bleeding signs (melena, hematemesis, trauma) suggests occult bleeding that requires identification 1, 2

Immediate Diagnostic Workup Required

Laboratory Assessment

• Complete blood count with serial hemoglobin measurements to assess ongoing blood loss 2
• Coagulation studies including PT/aPTT to evaluate anticoagulant activity 1
• Assessment for comorbidities contributing to bleeding (thrombocytopenia, uremia, liver disease) 1

Imaging Studies to Identify Bleeding Source

Gastrointestinal bleeding is the most common occult source in anticoagulated patients without overt signs:

• CT abdomen/pelvis with IV contrast to evaluate for retroperitoneal hemorrhage, intra-abdominal bleeding, or GI bleeding 1
• Consider esophagogastroduodenoscopy (EGD) and/or colonoscopy if GI source is suspected, as erosive gastritis and other mucosal lesions can cause significant bleeding without melena 3

Other critical sites to evaluate:

• CT head without contrast to rule out intracranial hemorrhage, especially given the severe baseline anemia 1
• Chest imaging if hemoptysis or respiratory symptoms develop 1
• Ultrasound or CT for retroperitoneal/psoas bleeding if back/flank pain present 1

Management Considerations

Anticoagulation Management

• Temporarily hold apixaban until bleeding source is identified and controlled 1, 2, 4
• Do NOT routinely administer reversal agents (andexanet alfa) for non-major bleeding without hemodynamic instability 1
• Consider reversal only if bleeding progresses or critical site identified 1, 2

Supportive Care

• Transfuse packed red blood cells to maintain hemoglobin ≥7 g/dL (or ≥8 g/dL if coronary artery disease present) 1
• Volume resuscitation with isotonic crystalloids if hemodynamically unstable 1
• Early involvement of appropriate specialty (gastroenterology, surgery, interventional radiology) once source identified 1

Critical Pitfalls to Avoid

Do not assume the absence of melena or hematemesis rules out GI bleeding. Occult GI bleeding is common in anticoagulated patients and may not present with classic signs initially. 3

Do not delay imaging while waiting for "more obvious" bleeding signs. In a patient with baseline hemoglobin of 7 g/dL, any further drop represents a medical emergency requiring immediate source identification. 1, 5

Recognize that apixaban dosing may have been inappropriate. A drop in hemoglobin on correct apixaban dosing is documented as a rationale for dose adjustment or discontinuation in hospitalized patients. 1 This patient's severe baseline anemia (Hb 7 g/dL) may have represented a contraindication to starting full-dose anticoagulation without first identifying the cause of anemia.

Do not restart anticoagulation until:

• Bleeding source is identified and controlled 2, 6
• Risk of rebleeding is assessed and minimized 2, 6
• The indication for anticoagulation is reassessed against bleeding risk 2, 6